Analysis of hearing effects of three ossicular reconstruction methods in 123 cases of atticotomy surgery
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摘要: 目的 回顾性分析123例行上鼓室切开重建患者的临床资料,探讨此类术式患者临床特点及听力重建方式的疗效。方法 将123例行上鼓室切开重建患者按照听骨链处理方式将其分为保留听骨链组(37例)、软骨加高镫骨组(49例)、部分人工听骨搭桥(PORP组,37例),分析行上鼓室切开重建患者的临床特点、3组患者术前和术后的听力水平、术后出现并发症情况。结果 ① 行上鼓室切开重建的患者中89.43%(110/123)为松弛部胆脂瘤,10.57%(13/123)患者为继发性胆脂瘤、粘连性中耳炎、紧张部胆脂瘤、先天性胆脂瘤、外耳道胆脂瘤;②保留听骨链组较其他2组患者病史更短,差异有统计学意义(P < 0.001),保留听骨链组术前在500、1 000、2 000、4 000 Hz频率下组间ABG值及平均ABG值较其他2组小,差异有统计学意义(P < 0.001);3组患者术前和术后的各频率ABG及平均ABG差异有统计学意义(P < 0.05);术后ABG:保留听骨链组较其他2组小,差异有统计学意义(P < 0.05),软骨加高镫骨组和PORP组之间差异无统计学意义(P>0.05);③术后3个月时所有患者均实现干耳,2例术后出现迟发性面瘫保守治疗后均痊愈,1例因锤砧固定术中磨钻影响术后出现骨导轻度下降,1例因术中残留术后4年复发,81例(65.85%)患者术后随访时间内出现非软骨修复区域内陷,其中5例(4.07%,5/123)因此复发行二次手术,其余患者虽局部有内陷但仍可自洁未形成胆脂瘤不需二次手术,总复发率4.88%(6/123),平均复发时间4年。结论 上鼓室切开重建术最常应用于范围较局限的松弛部胆脂瘤,术后上鼓室内陷袋发生率较高,需坚持定期随访;术中条件允许时可优先选择保留听骨链,其术后听力更好。采用软骨加高镫骨和PORP植入都可有效提高听力且术后二者听力无差别,但PORP术后有脱出的风险且费用昂贵,而软骨高度不够和镫骨头侵蚀时不适合采用软骨加高镫骨重建,因此需根据病情综合选择听力重建方式。Abstract: Objective Retrospective analysis of clinical data of 123 patients with atticotomy, exploring the clinical characteristics of patients undergoing atticotomy and the efficacy of hearing reconstruction methods.Methods 123 patients with atticotomy were divided into three groups according to the ossicular chain treatment method: preservation of the ossicular chain group(37 cases), cartilage elevation of stapes group(49 cases), and PORP group(37 cases). The clinical characteristics of patients with atticotomy, preoperative and postoperative hearing levels of the three groups of patients, and postoperative complications were analyzed.Results ① 89.43%(110/123) of patients who underwent atticotomy were pars flaccida cholesteatomas, while 10.57%(13/123) of patients were secondary cholesteatoma, adhesive otitis media, pars tensa cholesteatomas, congenital cholesteatoma, and external auditory canal cholesteatoma; ②The group with preserved ossicular chain had a shorter medical history compared to the other two groups, and the difference was statistically significant(P < 0.001). The group with preserved ossicular chain had smaller inter group ABG values and average ABG values at frequencies of 500 Hz, 1 000 Hz, 2 000 Hz and 4 000 Hz before surgery compared to the other two groups, and the difference was statistically significant(P < 0.001); The differences in ABG frequencies and average ABG between the three groups of patients before and after surgery were statistically significant(P < 0.05); Postoperative ABG: The group preserving the ossicular chain had a smaller difference compared to the other two groups, with a statistically significant difference(P < 0.05). There was no statistically significant difference between the cartilage plus high stapes group and the PORP group(P>0.05); ③At 3 months post surgery, all patients achieved ear dryness. Two patients experienced delayed facial paralysis after conservative treatment, and all recovered. One patient had a slight decrease in bone conductivity due to the influence of grinding during hammer anvil fixation surgery, and one patient experienced a recurrence after 4 years due to residual surgery. 81 patients(65.85%) experienced non cartilage repair area invagination during postoperative follow-up, of which 5 patients(4.07%, 5/123) underwent a second surgery. Although the rest of the patients had local invagination, they could still self clean and did not form a cholesteatoma. The total recurrence rate was 4.88%(6/123), with an average recurrence time of 4 years.Conclusion Atticotomy surgery is most commonly used for pars flaccida cholesteatomas with limited scope. The incidence of postoperative retraction is high, and regular follow-up is necessary; When conditions permit during surgery, priority can be given to preserving the ossicular chain for better postoperative hearing. Both cartilage elevation of stapes and PORP implantation can effectively improve hearing, and there is no difference in postoperative hearing between the two methods. However, there is a risk of detachment and high cost after PORP surgery, and cartilage elevation of stapes is limited by insufficient height and stapes head erosion. Therefore, it is necessary to choose a comprehensive hearing reconstruction method based on the patient's condition.
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Key words:
- atticotomy /
- cholesteatoma /
- ossicular chain /
- artificial ossicles
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表 1 3组研究对象一般资料的比较
组别 年龄/岁 性别/例 病史/年 男 女 保留听骨链组 31.30±13.27 20 17 1(0.5, 2.0) 软骨加高镫骨组 35.42±14.39 22 27 4(2.0, 13.0) PORP组 32.50±11.54 25 12 2(1.0, 13.0) 统计量 0.989 13.604 P 0.376 0.562 < 0.001 表 2 术前3组在各频率气骨导差的比较
M(P25,P75) 组别 术前500 Hz 术前1 000 Hz 术前2 000 Hz 术前4 000 Hz 术前平均ABG 保留听骨链组 20(25,0) 20(27,5) 5(12,5) 10(25,0) 16.25(21,25) 软骨加高镫骨组 35(22,5)1) 35(25,0)1) 20(20,0)1) 25(22,5)1) 27.50(21,25)1) PORP组 40(10,0)1) 35(10,0)1) 20(10,0)1) 30(25,0)1) 31.25(11,25)1) 与保留听骨链组比较,1)P < 0.01。 表 3 3组研究对象术前和术后气骨导差比较
M(P25,P75) 频率 500 Hz 1 000 Hz 2 000 Hz 4 000 Hz 平均ABG 保留听骨链组 术前 20(25,0) 20(27,5) 5(12,5) 10(25,0) 16.25(21,25) 术后 0(17,5) 0(20,0) 0(10,0) 0(10,0) 0(15,63) Z1 -3.426 -3.553 -1.977 -2.749 -3.381 P1 < 0.001 < 0.001 < 0.05 < 0.05 < 0.001 软骨加高镫骨组 术前 35(22,5) 35(25,0) 20(20,0) 25(22,5) 27.50(21,25) 术后 20(22,5) 20(22,5) 10(17,5) 20(22,5) 16.25(18,75) Z2 -4.365 -3.904 -3.852 -3.723 -4.357 P2 < 0.001 < 0.001 < 0.001 < 0.001 < 0.001 PORP组 术前 40(10,0) 35(10,0) 20(10,0) 30(25,0) 31.25(11,25) 术后 20(15,0) 20(12,5) 10(10,0) 20(15,0) 17.50(8,75) Z3 -4.865 -4.26 -3.463 -3.985 -4.701 P3 < 0.001 < 0.001 < 0.001 < 0.001 < 0.001 表 4 术后3组研究对象在各频率气骨导差的比较
M(P25,P75) 术后500 Hz 术后1 000 Hz 术后2 000 Hz 术后4 000 Hz 术后平均ABG 保留听骨链组 0(17,50) 0(20,0) 0(10,0) 0(10,0) 0(15,63) 软骨加高镫骨 20(22,5)1) 20(22,5)1) 10(17,5)1) 20(22,5)1) 16.25(18,75)1) PORP组 20(15,0)1) 20(12,5)1) 10(10,0)1) 20(15,0)1) 17.50(8,75)1) 与保留听骨链组比较,1)P < 0.01。 -
[1] 中华医学会耳鼻咽喉头颈外科学分会耳科学组, 中华耳鼻咽喉头颈外科杂志编辑委员会耳科组. 中耳炎临床分类和手术分型指南(2012)[J]. 中华耳鼻咽喉头颈外科杂志, 2013, 48(1): 5-5.
[2] Sanna M, Facharzt AA, Russo A, et al. Modified Bondy's technique: refinements of the surgical technique and long-term results[J]. Otol Neurotol, 2009, 30(1): 64-69. doi: 10.1097/MAO.0b013e31818edf17
[3] 龙瑞清, 高竞逾, 杨晶, 等. 软骨嵌合修复上鼓室外侧壁在乳突切开鼓室成形中的应用[J]. 中华耳科学杂志, 2019, 17(3): 364-370.
[4] Wullstein SR. Osteoplastic epitympanotomy[J]. Ann Otol Rhinol Laryngol, 1974, 83(5): 663-669. doi: 10.1177/000348947408300515
[5] McElveen JT Jr, Chung AT. Reversible canal wall down mastoidectomy for acquired cholesteatomas: preliminary results[J]. Laryngoscope, 2003, 113(6): 1027-1033. doi: 10.1097/00005537-200306000-00020
[6] Dornhoffer JL. Retrograde mastoidectomy[J]. Otolaryngol Clin North Am, 2006, 39(6): 1115-1127. doi: 10.1016/j.otc.2006.08.002
[7] Udayabhanu HN, Singh A, Piccirillo E, et al. Relevance of Modified Bondy Mastoidectomy in Pediatric Cholesteatoma[J]. Indian J Otolaryngol Head Neck Surg, 2021, 73(4): 403-407. doi: 10.1007/s12070-020-01793-1
[8] Berrettini S, Ravecca F, de Vito A, et al. Modified Bondy radical mastoidectomy: long-term personal experience[J]. J Laryngol Otol, 2004, 118(5): 333-337. doi: 10.1258/002221504323086499
[9] Pontillo V, Barbara F, DE Robertis V, et al. Treatment of cholesteatoma with intact ossicular chain: anatomic and functional results[J]. Acta Otorhinolaryngol Ital, 2018, 38(1): 61-66. doi: 10.14639/0392-100X-1564
[10] 韩宇, 刘嘉伟, 陈阳, 等. 上鼓室切开重建术与Bondy改良乳突根治术治疗Ⅰ期松弛部胆脂瘤的疗效比较[J]. 临床耳鼻咽喉头颈外科杂志, 2019, 33(6): 537-541. https://lceh.whuhzzs.com/article/doi/10.13201/j.issn.1001-1781.2019.06.015
[11] Smouha EE, Javidfar J. Cholesteatoma in the normal hearing ear[J]. Laryngoscope, 2007, 117(5): 854-858. doi: 10.1097/MLG.0b013e318033c2d6
[12] Walker PC, Mowry SE, Hansen MR, et al. Long-term results of canal wall reconstruction tympanomastoidectomy[J]. Otol Neurotol, 2014, 35(6): 954-960. doi: 10.1097/MAO.0b013e3182a446da
[13] 温立婷, 李旭, 高伟, 等. 17例中耳术后迟发性面瘫的临床特征分析[J]. 山东大学耳鼻喉眼学报, 2022, 36(5): 1-5.
[14] 张瑾, 王冰, 杨启梅, 等. 全耳内镜下经外耳道上鼓室胆脂瘤手术分析[J]. 中华耳科学杂志, 2017, 15(4): 420-425.
[15] 赵丹珩, 刘阳, 孙建军, 等. 保留外耳道后壁上鼓室切开软骨重建术治疗中耳胆脂瘤[J]. 听力学及言语疾病杂志, 2013, 21(5): 447-450.
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